Improved Dose Estimates for Fluoroscopically Guided Lumbar Epidural Injections

• Published in: Pain medicine (Malden, Mass.) Mass.), 2019-05, Vol.20 (5), p.971-978
• Main Authors: Mann, Steve D, Joshi, Anand, Shonyo, Megan, Wells, Jered R, Hoye, Jocelyn, Agasthya, Greeshma, Reiman, Robert, Samei, Ehsan
• Format: Article
• Language: English
• Subjects: Adrenal Cortex Hormones - administration & dosage; Backache; Care and treatment; Dosimetry; Drug dosages; Epidural injections; Fluoroscopy; Fluoroscopy - methods; Humans; Injections; Injections, Epidural - methods; Kinetic energy; Lumbosacral Region; Medical imaging; Methods; Pain management; Patient safety; Patients; Radiation Dosage; Radiation dosimetry; Radiography, Interventional - methods; Radiometry - methods; Spine
• ISSN: 1526-2375; 1526-4637
• DOI: 10.1093/pm/pny172

Abstract Objective The goal of the study was to determine the potential impact of system inaccuracies and table attenuation on fluoroscope-reported dose values. Design An Institutional Review Board–approved study was conducted to collect detailed acquisition and patient exposure data for fluoroscopy-guided lumbar epidural injections. Background System-reported dosimetry values, especially the air Kinetic Energy Released per unit MAss and dose-area product metrics, are routinely used for estimating the radiation burden to patients undergoing fluoroscopy-guided procedures. However, these metrics do not account for other factors, such as acquisition geometry, where the table may attenuate a substantial fraction of the x-ray intensity, and system dosimetry inaccuracies, which are only required to be accurate within ±35%. Methods Acquisition data from 46 patients undergoing fluoroscopy-guided lumbar epidural injections were collected to better estimate the true incident dose-area product. Gantry angles, x-ray technique factors, and field sizes were collected to characterize each procedure. Additionally, the fluoroscope dosimetry accuracy and table attenuation properties were evaluated as a function of kVp to generate the correction factors necessary for accurate dosimetry estimates. Results The system-reported values overestimated the total patient entrance dose-area product by an average of 34% (13–44%). Errors may be substantially higher for systems with less accurate fluoroscopes or more anterior–posterior projections. Correcting system-reported dosimetry values for systematic inaccuracies and variability can substantially improve fluoroscopic dose values. Conclusions Including corrections for system output inaccuracies and acquisition factors such as table attenuation is necessary for any reliable assessment of radiation burden to patients associated with fluoroscopy-guided procedures.